Health Homes

Description“Health homes” provide beneficiaries with chronic conditions comprehensive care management, care coordination, transitions from inpatient to other settings, family supports, and referrals to community and support services. Conceptually, they resemble PCMH but are not necessarily based in a primary care setting and do not provide (but may assist in the coordination of) medical services. By better coordinating care and linking people to needed social services, health homes are designed to improve health care quality and reduce costs.A “medical home” is an advanced model of primary care focused on the coordination of patient-centered care.  The medical home relies on a team of providers to meet a patients needs and to improve access to care (e.g., through increased communication between providers and patients; longer office hours; primary care in the home etc.). There is no uniform definition for a PCMH, though the National Committee for Quality Assurance (NCQA) offers accreditation and certification.  
Patient PopulationMedicaid beneficiaries diagnosed with: (1) two chronic conditions; (2) one chronic condition and risk for a second; or (3) a serious mental illness. The statute creating health homes identified the following chronic conditions: mental health conditions, substance use disorder, asthma, diabetes, heart disease, and overweight (body mass index over 25). States may propose other conditions to CMS for incorporation into their health home models.
Typical LeadA wide range of providers participate in the health home care team. A single entity is designated as the lead and has responsibility for ensuring that the patient is receiving all needed services, including those based in the community. Given the wide array of services required in a health home model, the remaining team is generally virtual.  Each state defines who may run a health home but federal policy permits home health agencies to be a designated health home. 
Role of Home HealthHome health agencies can be designated as the “health home” provider or may provide services directly to the patient in coordination with the virtual care team.
Reimbursement ModelHealth homes receive a monthly per member per month (PMPM) care coordination fee from payers. Health homes may contract with service providers, such as HHAs, on either a PMPM or a fee-for-service basis.
Minimum Infrastructure RequirementsData analytics to identify high risk patients for specialized care coordination servicesIntegration between medical and social services
ResourcesCMS Health Home Resource Center